Description

Experimental/Investigational services are defined as a treatment, procedure, facility, equipment, drug, service or supply (“intervention”) that has been determined not to be medically effective for the condition being treated.

This policy addresses services considered to be experimental/investigational and, therefore, non-covered services.

Criteria

Charges submitted for the services listed in this policy are denied as experimental/investigational. The determination for denial is based on ANY of the following reasons:

• The intervention does not have Food and Drug Administration (FDA) approval to be marketed for the specific relevant indication(s); or
• Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes; or
• The intervention is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or
• The intervention does not improve health outcomes; or
• The intervention is not proven to be applicable outside the research setting.

The following procedure codes are considered experimental/investigational and, therefore, non-covered. Scientific evidence of safety and efficacy has not been proven.

Procedure Codes

Outpatient HCPCS (C Codes)